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COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OP NATURAL RESOURCES <br />1313 SHERMAN ST, RM INC DENVER. CO 50203 <br />phone - int:1303) 4664567 mdrc (3C3) 866 -3681 <br />580 'Jp:'NA1w.Weter.state. W_us <br />f ac (303) 6663 't <br />Office Uee Only RECEIVED' 1-cum WWS (13.1-2008) <br />NOV 0 5 2009 <br />77 � <br />W ST A TE N INFER <br />Cur.$ <br />GENERAL PURPOSE <br />Water Well Permit Application <br />Review Instructions on memo ekle prior to completing Dorm. <br />The form must be ooalplstsd l0 black or blue ink or typed. <br />1. Applicant Information <br />6. Use Of Well (check applicable boxes) <br />Attach a detoled description of uses applied for. <br />0 InduStriel ❑ Dewaterkg SYSken <br />0 M11181C:pa 0 Geothermal (❑ production or ❑ rein eckon) <br />0 kr)p:r•Jon ® gather tdasc1be) Dasestle use -Mine McInnes and <br />f Canwetdal Dinemow' <br />Nunn rpkart <br />Colorado Board of Land Commissioners <br />made; addw,s <br />P.D. Hoot 1194 - <br />be aria 626 <br />Craig i CO i 81 <br />7. Well Data (proposed) <br />. net <br />1 970 ' 1114 <br />Ilaxmlni Await llal again how aarawI <br />10 10 (estimated mmdamm) av ian! <br />-3mt. <br />2. Type Of Application (check applicable boxes) <br />66 Constnxt vex well ❑ Change source (aquifer) <br />❑ Replace ownp wN ❑ Reapplication (expired Derma) <br />a <br />p use wasting we ❑ CGDCC well <br />❑ Change or increase use ❑ Mac <br />r <br />300 TroutCra.k Sandstone <br />tae: <br />8. Land On Which Ground Water Will Be Used <br />Legal Desolation ra'ay an rowan as an =emu r <br />, r. uscIN ens :lemon. met a SCOW man Mal shone rep= area: <br />3. Refer To (it applicable) <br />' 7tRera- ..c.r.=fa <br />• <br />oWyteo Sam Ma,nirn:ana tat <br />4 Location Of Proposed Well (Important! See Instructions) <br />Ca,arj r <br />Rook NR 1udU. NE 1!' <br />A. *Apes :` 6. Grin <br />WA MIA <br />- S o .a • 3 C N T; _ 7 r M1. <br />3 i5 M 0 • a7 D ® ; 6 PM <br />Z. Ls: a air/ Aar 94l.aa `47:arb Law cnmbat <br />No water rights lilted 9w bat section <br />coat d mown mew BM{:warn Name tocatr:lci Notary: seer <br />550 rote' ❑ N i0 S 475 r_I= 0 E Oa W <br />9. Proposed Well Driller License #( nal - <br />-cs tm�ntra* Karr +r- dra- teanddttawIamut,rNaanrK« <br />foot direction <br />10. Signature Of Applicant(s) Or Aut on Agent <br />The malting of false sidemen's herein cacLSL•tutns parry in Om second <br />comp, wfich Is punishable as a doss I misds:nearer purstsui to C.R.S. <br />24 -4-104 (13)(0) I he read the statements herefr. know the contents <br />thereof and slide t0: they are true 13 ur� lmmMec e <br />Vitt rceaa aseren txardd Ctr Mahe Da! ea Chey. aSmis sa:raas la um <br />Wat- "ie .Yuri n a ►p+f *mos', — �SaY <br />opeote : OP5 :Ml:!'eat= rMamoun In U11.1 ranat You must check GPs tit 1b• <br />rcqurea edt nos es rams <br />Fur st malt! MA <br />D 7mra 1•s aril 2cn. u 1 Foamy 319603.9 <br />°rncenre $ eh <br />;rue MLLE I* Won i e <br />mon be NAM i NCde''Iy 4;77106, <br />Office Use Only <br />.tea fauna as to fun � ■ <br />Was Gaff u33 r taco ta• Naze ® %Ts . Rameteber to set Daum to NAD13 <br />.39&.9 m1; nano i Mk nag v. 9r'acsaNv <br />r <br />5. Parcel On Which Well Wilt Be Located <br />(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) <br />• Ice o es ay <br />% Fe Gusa t f; y C.lc <br />7% +6 ift vyei% ir.w., <br />/OIL ea; i t �I 3 /9_(//01 <br />• <br />A Legal oese Spann owes mama os 3n aseettrer:, <br />TSN RIM IN SEC 1.3. l0-12. <br />Ii 8.3 ;cr suet a paw I C. numb State teed Salad <br />1 2 , <br />AO.. eC ' — A<o o //' 04 w a vat ✓ j. .. , GOO' .9 ( Ste 3 <br />WE - ec.e 3- 3 �r, I ) and its <br />'SR <br />r-1 <br />C. :141weistaariy /Of a - "Is Favor;0rss MCfone •Imatir+Mls: <br />can Pm*: ax,estc -a r <br />Parcel 4 944024001, Amato. 1111051237 <br />Ta <br />R'YU,a <br />STra DN 4 L4T BA <br />Nov 05 09 05:30p State Land Board <br />9708243036 <br />ArOc.c-p & lo /o `i `/ <br />Czt(r /Ae4e 05 <br />p.2 <br />tNSc --•�► WTaef; Ale IA/E leg. 3 ,T Sf, aS'7t4 <br />S4 • 'Af S 4- <br />93S'rEs <br />